1821055492 NPI number — DR. SCOTT A BRODARICK M.D.

Table of content: DR. SCOTT A BRODARICK M.D. (NPI 1821055492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821055492 NPI number — DR. SCOTT A BRODARICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODARICK
Provider First Name:
SCOTT
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821055492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 3RD ST STE 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97034-3082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-783-6907
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 SE STRATUS AVE UNIT 406
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-6258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-472-6131
Provider Business Practice Location Address Fax Number:
503-434-9572
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  DR.0066849 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: R6974 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: MD208805 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 305031 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 218048 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 200385417 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366126 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4415401 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com